The C2C Telephone Discussion: What is it and Should You Do It?

This is a special guest post from Stephanie Morgan Greene of The Audit Team, a division of Morgan Greene Consulting, LLC. She has been a part of the DMEPOS industry for over 20 years, starting her career as a respiratory therapist, then continuing as an attorney and consultant to the DMEPOS industry. The Audit Team draws on Stephanie's extensive experience providing focused Medicare coverage and documentation guidance to O&P practitioners.

In 2016, CMS initiated the trial of a new process for appealing certain claims at the Reconsideration appeal level called the "Formal Telephone Discussion Demonstration." Under this Demonstration, C2C Innovative Solutions, Inc. ("C2C"), the contractor overseeing the Reconsideration Level of appeal, would provide suppliers the opportunity to participate in a telephone discussion as part of the appeal. This gave the supplier the opportunity to explain the reason why the claim should be paid, and essentially make his or her case for payment. If C2C found documentation was missing, the supplier was given an additional 14 days after the hearing to provide the documentation as part of the appeal.

The primary drawback to the Demonstration process was how limited it was in scope. For instance, only suppliers in Jurisdictions C and D were able to participate and the only types of claims included were oxygen and diabetic supplies. The Demonstration also limited a single supplier to a maximum of five claims. And probably the most important limitation of all was the fact that only the suppliers chosen by C2C had the opportunity to participate.

For those suppliers that were given the chance to participate in the Demonstration, the outcome was extremely positive. 80% of the appeals reviewed through this process had favorable outcomes for the suppliers – meaning 80% of the time the supplier won the appeal! In my personal experience with the Formal Telephone Discussion Demonstration, the success rate was even higher.

Starting October 31, 2016, CMS and C2C expanded the claim types allowed to take part in a Telephone Discussion to include O&P claims, and they have also removed the 5-claim limit. O&P providers may now have an opportunity to speak with the C2C employee who is reviewing their claims, giving them the opportunity to discuss the case before the appeal decision is made.

Similar to the Demonstration, C2C will still select the suppliers to participate and will limit their selection to suppliers in Jurisdiction C and D. The hope is the next phase of the Telephone Discussion will be as positive as the Demonstration and we will see the process opened up even more to cover all jurisdictions.

If you operate in Jurisdictions C or D and are selected for a Telephone Discussion, I encourage you to take advantage of the opportunity. C2C will notify you in writing that you have been selected, and provide you with a date and time for the hearing. The hearing itself is not adversarial, and the C2C employees are very open to taking the time to walk through the documentation. At the beginning of the call they will explain the process to you and allow you to discuss the different documentation you have provided. I found C2C listened to my position and provided me with valuable feedback on how the documentation was being reviewed and considered for payment.

If you are chosen, don't waste the opportunity! With a little preparation and a short telephone call, you too may see the positive benefits of getting to speak directly with the reviewer – most notably, the quick resolution of your claim without having to wait years for an ALJ hearing. And hopefully, this will be only the first step CMS takes in improving the audit and appeal process!